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Endoscopy Surgery Fertility Enhancement

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Endoscopy Surgery Fertility Enhancement

What is Endoscopic Surgery?

Endoscopic surgery is a surgery in which long telescope like instruments are used through small incisions or natural body openings in order to diagnose and treat disease. Another popular term is minimally invasive surgery (MIS), which emphasizes that diagnosis and treatments can be done with reduced body cavity invasion.

Commonly performed endoscopic surgeries in infertility management are laparoscopy (instrument introduced through the abdomen to visualize the womb and its surroundings like the fallopian tube and ovaries from above) and hysteroscopy (instrument introduced through vagina and cervix to visualize the inside of the womb). Both of these can be either diagnostic (to diagnose the cause leading to infertility) or operative (to treat the condition leading to infertility ).

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At Ankoor fertility clinic we offer all kind of endoscopic surgeries, both diagnostic and operative under one roof. In certain cases while doing diagnostic surgeries if some disease or condition is diagnosed which requires operative intervention, then the same is also done (only after the consent of the couple) in the same sitting.

For example, if on doing a diagnostic laparoscopy, we find that there is some endometriosis (discussed in details later), we fulgurate (cauterize or burn the unhealthy and abnormal tissue) .

This helps to reduce the burden of undergoing another operative procedure to the patient, which in turn reduces the risk of another anaesthesia, cost of surgery and also fewer days for recovery .

Some of the common indications for using endoscopic surgeries in infertility

Laparoscopy:

Endometriosis

Fibroids

PCOS

Pelvic Inflammatory Diseases / Hydrosalpinx

Hysteroscopy:

Uterine Polyp

T-Shaped Uterus

Uterine Septum

Asherman Syndrome / Uterine Adhesions

Submucous Or Intramural Fibroid

Tubal block

Tubal cannulation is a procedure by which proximal end of fallopian tube can be opened with the help of cannulation wire by hysteroscopy and laparoscopy simultaneously.

Hysteroscopy is done initially and uterine cavity, both tubal opening are observed.

Laparoscope is introduced through abdomen and methylene blue dye is pushed, free spill from either of the tubes is observed.

This is called as selective tubal cannulation.

This procedure is done only in case of proximal tubal block. Whenever there are pathologies on the distal end of the tubes such as, fimbrial agglutination, adhesions to the ovaries, pelvic inflammatory disease, endometriosis, tubal cannulation might lead to implantation of the pregnancy outside the uterus (ectopic pregnancy).    

So it is done only when distal tubal end is normal devoid of any above pathologies and normal semen parameters.

Cannulation catheter with guide wire (instrument to open the block) is passed from the uterine cavity towards the tubal opening, just a centimeter forward.


What is Laparoscopy ?

Laparoscopy is a procedure that involves insertion of a narrow telescope-like instrument through a small incision in or near the belly button. This allows visualization of the abdominal and pelvic organs including the uterus, fallopian tubes and ovaries. Laparoscopy is sometimes referred to as ‘band-aid’ surgery since the incisions are very small and usually covered with a band-aid (Steri-strip). Some people refer to it as a key- hole surgery or minimally invasive surgery.

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Normal Uterus with bilateral tubes and ovaries on diagnostic laparoscopy

Do all women with infertility need to undergo this surgery?

No.

Laparoscopy is not indicated as a routine investigation in all women who have difficulty in conceiving.

There are specific indications for undergoing laparoscopy and the decision for the same is taken in consultation with your infertility specialist.

What are the indications for laparoscopy?

Laparoscopy is indicated whenever the history of the patient, clinical examination or other investigations such as Ultrasonography (USG) or Hysterosalpingography (HSG) indicate an abnormality in pelvic region. Hysteroscopy usually goes hand in hand with laparoscopy.

Common indications being:

Diagnostic laparoscopy – It is generally done to visualize check whether the uterus and its surrounding structures are normal. A blue coloured dye can be injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open (chromopertubation).


Endometrioma (Cyst in ovary containing blood)

Hydrosalpinx or pyosalpinx (Infective fluid or pus in uterine tubes)
Pelvic adhesions (sticky bands similar to what is seen when there is fevicol smeared in between our fingers ) with or without tubo ovarian mass (Usually these occur following infection in pelvic region)
Bulky polycystic ovaries (PCOS) not responding to medical line of management
Fibroids of uterus

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Failure of IUI (Intrauterine insemination) – When more than 6 consecutive cycles have not been able to achieve pregnancy.

Prior to IVF (if needed) – Sometimes the history of the couple and previous investigations lead to the conclusion that IVF (test tube baby) may be needed. In these cases endoscopic surgery may be needed to visualize the uterine cavity, particularly its lining on hysteroscopy and uterus or ovaries on laparoscopy for any abnormality which can be corrected prior to the procedure.

In women with long term unexplained infertility (where all other standard or routine investigations are normal). In these cases endoscopic surgery (Laparoscopy or hysteroscopy) may be needed to search for any factor which may have been missed by routine non invasive tests like USG ( ultra sonography) or HSG (Hysterosalpingography)

Endometrioma
Endometrioma is also called as endometriotic cyst, which is found in ovary.
It can be unilateral (only in one sided ovary) or bilateral (in both ovaries)

How to operate on endometriotic cyst?

1) Locate endometrioma  and its realtion to the rest of the ovary and part of the uterus

2) Incision (cut) taken on surface of the endometrioma

  3) Separating the endometriotic cyst with its cyst wall from the rest of the healthy ovary

Separating the endometrioma with its cyst wall avoids chances of recurrence of endometrioma
Ankoor fertility clinic prefers the same method

4) One should assure that there are no bleeding points in the surgical field. Minimal use of electrical energy (bipolar) or couple of sutures can be taken to stop the bleeding in case

Endometriosis

( Staging done by laparoscopy – as a gold standard )

Adhesions – These are the pathological connections formed between different reproductive organs or within one organ

It can be due to previous infections or previous surgeries

For example – adhesions formed between fallopian tubes and ovary will disturb tubo-ovarian relationship and affect the pickup of oocyte by fimbria
Adhesions formed inside uterus will affect the chances of pregnancy getting implanted inside the uterus
That is why adhesiolyis (breaking these adhesions ) improves the rate of fertility in future times


FIBROID

How to diagnose fibroids –

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1. Transvaginal 2D/3D sonography

2. Fluid contrast sonography – (sonohysterogram) – to establish relationship between fibroid with the uterine cavity in case of submucous fibroid

If the size of submucous fibroid is bigger we give medical therapy f or 3-6 months and size is reduced. such fibroids are easy to take out in one surgery which otherwise might have taken one or more surgeries

3. MRI – used when there are more numbers of fibroids ( more than 5-7 ) to get information about exact location of fibroids from the endometrium and outer surface. This is called as “fibroid mapping “ – for surgical accuracy (image

Plan of surgery is decided pre operatively after one of these investigations

  •     Depending on location of fibroid
  •     It’s distance from serosa ( outermost layer of uterus )

  • It’s distance from mucosa ( innermost layer of uterus )
  • Number and site of incision

How we operate on fibroid :

Step 1 – locate fibroid and inject inj. Vasopressin in particular dilution with saline . This injection helps in reducing blood flow to fibroid ( by constricting the vessels supplying fibroid ). This is needed as fibroid is very vascular organ .

Step 2 – taking incision on fibroid depending on type of fibroid

Step 3 – inserting a screw like device ( myoma screw ) in fibroid to take out the fibroid from its capsule inside the uterus

Step 4 – suturing of uterus at the site from where myoma is removed ( myoma bed ) with absorbable suture material in 2 -3 layers

Step 5 – removing the myoma outside the abdomen by use of special instrument called as morcellator. It uses mechanical energy to make small pieces of fibroids in the form of strips an then taken out of the abdomen through same incision


What do you mean by diagnostic laparoscopy and operative laparoscopy?

Diagnostic laparoscopy is performed as a part of investigation for infertility in cases where no abnormality is detected on non invasive tests like USG (ultrasound) or HSG (hysterosalpingography). It is usually performed in women with unexplained infertility, following failure of repeated IUIs or along with operative hysteroscopy. The pelvic anatomy is visualized with a telescope like instrument. The uterus, tubes, ovaries and there surrounding structures are systematically checked. A blue coloured dye is injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open. This is known as chromopertubation.

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Diagnostic Laparoscopy  Video

Video Bilateral Tubo Ovarian Mass

Diagnostic or operative hysteroscopy usually accompanies this procedure.

A review of literature shows that even among women whose tubes were found to be unobstructed or patent (open) using HSG (which shows the inside image of the fallopian tubes), 18% were found to have tubal obstruction or peritubal adhesions (outer side of the fallopian tubes) using laparoscopy and a further 34% were found to have endometriosis or fibroids (again outer side of the fallopian tube is involved or compressed). These conditions remain silent and cannot be diagnosed on non invasive tests (USG or HSG).

If there is any abnormality like fibroids, endometriosis, pelvic adhesions or blocked tubes, these can be tackled at the same time.

Many a times a diagnostic laparoscopy is done along with operative hysteroscopy in cases like hysteroscopic fibroid removal and septum resection for extra seafety of the patients, to know the end point and to prevent complications like uterine perforation.

Whenever some surgery is performed in addition to chromopertubation, like removal of fibroid, endometrioma removal, fulguration (burning) of endometriosis, adhesiolysis(separation of adhesions in pelvis) or delinking of hydrosalpinx or pyosalpinx, is called operative laparoscopy.

How is laparoscopy performed?
Laparoscopy procedure is usually done as a day care surgery (you can get admitted, undergo surgery and discharged on the very same day or the next day but generally within 24 hours) under general anaesthesia. It usually takes about few minutes to less than an hour.

During this procedure a small cut is made on or near the belly button (this leaves a minute scar which is almost invisibles). A telescope (laparoscope) is then inserted through the umbilicus and gas (carbon dioxide) is pumped into the abdomen to push the intestine away. A powerful light is then shone down through the laparoscope.

The endoscopic surgeon then inspects the inside of the abdomen and pelvis including the outside of the womb / uterus, the tubes and ovaries as seen on the video monitor.
A second incision (1-1.5cm) is also made on the left or right lateral side of the lower abdomen so that another probe can be inserted in order to move pelvic organs such as the ovaries or bowels to get a clear view. A blue coloured dye (methylene blue) is then injected through the cervix (mouth of uterus). If the tubes are not blocked the dye should pass along them and spill into the abdomen.

If an abnormality is found during laparoscopy, this may be dealt with at the same time thus avoiding another operation. When performing operative laparoscopy such as opening of blocked tubes, cutting of adhesions and freeing of the tubes etc. additional instrument such as micro-scissors and forceps are placed in the abdomen through additional cuts generally on the lateral side of the abdomen.

When the surgery is completed, the gas is removed and a stitch is taken to close the incisions.

Is it a big procedure? How much work would I miss?

Diagnostic laparoscopy is a day care procedure and generally takes about 30 minutes. If on doing the laparoscopy any abnormality is seen like adhesions, cyst etc and operative work is required, the procedure might take a little longer. The woman is generally discharged home from the hospital on the same evening or the next day morning.

The woman will usually need to take off an additional 1-2 days from work following the procedure. Mild discomfort in the form of mild abdominal pain or shoulder tip pain, should be expected to last for up to 7 days or so after the procedure.

What are the complications of laparoscopy?

After the laparoscopy procedure the in about 3% of patients there may be some nausea, discomfort and shoulder tip pain, due to the gas that was injected into the abdomen. The discomfort usually lasts not more than 24-48 hours.

Major complications associated with operative laparoscopy include the possibility of damage to other structures in the pelvis such as the bladder, ureter, bowel and blood vessels. Unexpected open surgery (larger incision) is always a possibility, but is very uncommon.

Any surgery can have an anesthesia-related complication or be associated with post-operative infection, such as a skin infection at an incision site.
However when such surgeries are performed by experts with utmost care the possibility of complications is very rare.




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